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  1. Ascension Health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise. | PSNet

    psnet.ahrq.gov/issue/ascension-healths-demonstration-full-disclosure-protocol-unexpected-events-during-labor-and
    January 22, 2017 - Study Ascension Health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise. Citation Text: Hendrich A, McCoy CK, Gale J, et al. Ascension health's demonstration of full disclosure protocol for unexpected events during labor and deliv…

  2. Promoting health care safety through training high reliability teams. | PSNet

    psnet.ahrq.gov/issue/promoting-health-care-safety-through-training-high-reliability-teams
    January 06, 2018 - Commentary Promoting health care safety through training high reliability teams. Citation Text: Wilson KA. Promoting health care safety through training high reliability teams. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010090. Copy Citation Format: …

  3. Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians. | PSNet

    psnet.ahrq.gov/issue/greatest-impact-safe-harbor-rule-may-be-improve-patient-safety-not-reduce-liability-claims
    July 05, 2017 - Study Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians. Citation Text: Kachalia A, Little A, Isavoran M, et al. Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by p…

  4. Impact of a computerized physician order-entry system. | PSNet

    psnet.ahrq.gov/issue/impact-computerized-physician-order-entry-system
    October 19, 2022 - Study Impact of a computerized physician order-entry system. Citation Text: Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042. Copy Citation Format…

  5. Emergency department discharge prescription interventions by emergency medicine pharmacists. | PSNet

    psnet.ahrq.gov/issue/emergency-department-discharge-prescription-interventions-emergency-medicine-pharmacists
    September 22, 2021 - Study Emergency department discharge prescription interventions by emergency medicine pharmacists. Citation Text: Cesarz JL, Steffenhagen AL, Svenson J, et al. Emergency department discharge prescription interventions by emergency medicine pharmacists. Ann Emerg Med. 2013;61(2):209-214…

  6. Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients. | PSNet

    psnet.ahrq.gov/issue/evaluation-role-critical-care-pharmacist-identifying-and-avoiding-or-minimizing-significant
    December 15, 2021 - Study Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients. Citation Text: Rivkin A, Yin H. Evaluation of the role of the critical care pharmacist in identifying and avoidi…

  7. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. | PSNet

    psnet.ahrq.gov/issue/seven-hundred-and-fifty-nine-759-chances-learn-3-year-pilot-project-analyse-transfusion
    September 25, 2008 - Study Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. Citation Text: Lundy D, Laspina S, Kaplan H, et al. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project …

  8. Improving patient safety in critical care: big challenge, exciting opportunity/L'amelioration de la securite des patients a l'unite des soins intensifs : un grand defi, une occasion stimulante. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-critical-care-big-challenge-exciting-opportunitylamelioration-de-la
    December 22, 2018 - Commentary Improving patient safety in critical care: big challenge, exciting opportunity/L'amelioration de la securite des patients a l'unite des soins intensifs : un grand defi, une occasion stimulante. Citation Text: Dodek P. Improving patient safety in critical care: big challenge,…

  9. The use of patient pictures and verification screens to reduce computerized provider order entry errors. | PSNet

    psnet.ahrq.gov/issue/use-patient-pictures-and-verification-screens-reduce-computerized-provider-order-entry-errors
    November 16, 2022 - Study The use of patient pictures and verification screens to reduce computerized provider order entry errors. Citation Text: Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130(…

  10. Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey of users. | PSNet

    psnet.ahrq.gov/issue/preventing-dispensing-errors-alerting-drug-confusions-pharmacy-information-system-survey
    August 19, 2009 - Study Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey of users. Citation Text: Campmans Z, van Rhijn A, Dull RM, et al. Preventing dispensing errors by alerting for drug confusions in the pharmacy information system-A survey of use…

  11. Nursing surveillance: a concept analysis | PSNet

    psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
    May 26, 2021 - Review Nursing surveillance: a concept analysis Citation Text: Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460. doi:10.1111/nuf.12702. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…

  12. Detecting clinical medication errors with AI enabled wearable cameras. | PSNet

    psnet.ahrq.gov/issue/detecting-clinical-medication-errors-ai-enabled-wearable-cameras
    August 03, 2022 - Study Detecting clinical medication errors with AI enabled wearable cameras. Citation Text: Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2. Copy Citation Format: …

  13. Adoption of order entry with decision support for chronic care by physician organizations. | PSNet

    psnet.ahrq.gov/issue/adoption-order-entry-decision-support-chronic-care-physician-organizations
    October 06, 2011 - Study Adoption of order entry with decision support for chronic care by physician organizations. Citation Text: Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9. Copy …

  14. Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. | PSNet

    psnet.ahrq.gov/issue/work-arounds-and-artifacts-during-transition-computer-physician-order-entry-what-they-are-and
    January 12, 2022 - Study Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. Citation Text: Schoville RR. Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. J Nurs Care Qual. 2…

  15. The error of omission: a simple checklist approach for improving operating room safety. | PSNet

    psnet.ahrq.gov/issue/error-omission-simple-checklist-approach-improving-operating-room-safety
    August 03, 2022 - Commentary The error of omission: a simple checklist approach for improving operating room safety. Citation Text: Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0…

  16. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? | PSNet

    psnet.ahrq.gov/issue/increased-mortality-associated-weekend-hospital-admission-case-expanded-seven-day-services
    March 02, 2012 - Study Increased mortality associated with weekend hospital admission: a case for expanded seven day services? Citation Text: Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ. 2015;351:h4596.…

  17. Intentionally harmful violations and patient safety: the example of Harold Shipman. | PSNet

    psnet.ahrq.gov/issue/intentionally-harmful-violations-and-patient-safety-example-harold-shipman
    January 25, 2017 - Commentary Intentionally harmful violations and patient safety: the example of Harold Shipman. Citation Text: Baker R, Hurwitz B. Intentionally harmful violations and patient safety: the example of Harold Shipman. J R Soc Med. 2009;102(6):223-227. doi:10.1258/jrsm.2009.09k028. Copy C…

  18. Leader communication approaches and patient safety: an integrated model. | PSNet

    psnet.ahrq.gov/issue/leader-communication-approaches-and-patient-safety-integrated-model
    July 01, 2019 - Study Leader communication approaches and patient safety: an integrated model. Citation Text: Mattson M, Hellgren J, Göransson S. Leader communication approaches and patient safety: An integrated model. J Safety Res. 2015;53:53-62. doi:10.1016/j.jsr.2015.03.008. Copy Citation Forma…

  19. Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices. | PSNet

    psnet.ahrq.gov/issue/survey-evaluation-national-patient-safety-agencys-root-cause-analysis-training-programme
    March 11, 2009 - Study Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices. Citation Text: Wallace LM, Spurgeon P, Adams S, et al. Survey evaluation of the National Patient Safety Agency's Root …

  20. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. | PSNet

    psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity
    March 02, 2011 - Study Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. Citation Text: Grimes T, Delaney T, Duggan C, et al. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care.…
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